Covered California Provider Directory Data Submission: Guidelines, Standards… · 2020. 1. 27. ·...

Covered California Provider Directory Data Submission: Guidelines, Standards, and Specifications Version 1.10

Guidelines, Standards, and Specifications

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Contents 1.Revision History ......................................................................................................................................................................................................................... 6

2. Introduction ............................................................................................................................................................................................................................ 10

Purpose of this Document ...................................................................................................................................................................................................... 10

Intended Audience ................................................................................................................................................................................................................. 11

Supporting Documents ........................................................................................................................................................................................................... 11

3. General Approach to Provider Data Quality ........................................................................................................................................................................... 13

A. Timeliness: .......................................................................................................................................................................................................................... 14

B. Validity (Completeness): .................................................................................................................................................................................................... 15

C. Consistency (Reasonability): ............................................................................................................................................................................................... 18

D. Accuracy: ............................................................................................................................................................................................................................ 19

4. General data guidelines when creating and submitting file(s) ............................................................................................................................................... 22

A. Dealing with missing, unknown or non-applicable values ................................................................................................................................................. 22

B. Data Formats, Data Types and Standardizations ............................................................................................................................................................... 22

C. Row counts, row duplications and included provider types .............................................................................................................................................. 22

D. File Format and Naming Conventions ................................................................................................................................................................................ 23

E. File Transmission Guidelines .............................................................................................................................................................................................. 24

F. Communications between Covered California and Participating Issuers........................................................................................................................... 24

5. Submission File Layout ........................................................................................................................................................................................................... 26

A. Header record data elements ............................................................................................................................................................................................ 26

B. Detail Record Data Elements .............................................................................................................................................................................................. 29

C. Data Element Detail Descriptions ....................................................................................................................................................................................... 32

Last_Name .......................................................................................................................................................................................................................... 33

First_Name ......................................................................................................................................................................................................................... 34

Middle_Name ..................................................................................................................................................................................................................... 35

Provider_Type .................................................................................................................................................................................................................... 36

NPI ...................................................................................................................................................................................................................................... 38

CA_License .......................................................................................................................................................................................................................... 39


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Non_CA_License ................................................................................................................................................................................................................. 41

Non_CA_License_State ....................................................................................................................................................................................................... 43

Provider_Gender ................................................................................................................................................................................................................ 45

Provider_Language_1 ......................................................................................................................................................................................................... 46



Facility_Language_1 ........................................................................................................................................................................................................... 49



Type_of_Licensure.............................................................................................................................................................................................................. 52

Location_Address ............................................................................................................................................................................................................... 53

Location_Address_2 ........................................................................................................................................................................................................... 54

Location_Zip_Code ............................................................................................................................................................................................................. 55

Location_City ...................................................................................................................................................................................................................... 55

Location_County ................................................................................................................................................................................................................. 56

Location_Region ................................................................................................................................................................................................................. 56

Location_State .................................................................................................................................................................................................................... 57

Location_Phone .................................................................................................................................................................................................................. 58

Provider_Clinic_Name ........................................................................................................................................................................................................ 59

Provider_Clinic_ID .............................................................................................................................................................................................................. 59

Primary_Specialty ............................................................................................................................................................................................................... 60

Secondary_Specialty ........................................................................................................................................................................................................... 61

Medical_Group/IPA_1 ........................................................................................................................................................................................................ 63




Contract_Type .................................................................................................................................................................................................................... 65

Hospital_1 ........................................................................................................................................................................................................................... 66


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Hospital_2 ........................................................................................................................................................................................................................... 67

Hospital_3 ........................................................................................................................................................................................................................... 68

Hospital_4 ........................................................................................................................................................................................................................... 69

Hospital_1_OSHPD_ID ........................................................................................................................................................................................................ 70




Hospitalist_(Hosp_1) .......................................................................................................................................................................................................... 74




NPI_Sup_PCP ...................................................................................................................................................................................................................... 76

Sup_PCP_Specialty ............................................................................................................................................................................................................. 78

DEA ..................................................................................................................................................................................................................................... 80

Facility_Name ..................................................................................................................................................................................................................... 81

Facility_System ................................................................................................................................................................................................................... 82

OSHPD_ID ........................................................................................................................................................................................................................... 83

Type_of_Service ................................................................................................................................................................................................................. 84

Tertiary_Care ...................................................................................................................................................................................................................... 85

FTIN ..................................................................................................................................................................................................................................... 85

Last_Update ........................................................................................................................................................................................................................ 86

Plan_Year ............................................................................................................................................................................................................................ 87

Current_Assigned_Enrollees .............................................................................................................................................................................................. 88

PCP_Flag ............................................................................................................................................................................................................................. 89

Network_ID......................................................................................................................................................................................................................... 90

Network_Tier_ID ................................................................................................................................................................................................................ 91

Availability .......................................................................................................................................................................................................................... 92

Visibility .............................................................................................................................................................................................................................. 93


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Covered_California_ID ........................................................................................................................................................................................................ 94

ECP_Flag ............................................................................................................................................................................................................................. 94

Accepting_New_Patients ................................................................................................................................................................................................... 95

Snapshot_Date ................................................................................................................................................................................................................... 95

Issuer_Provider_ID ............................................................................................................................................................................................................. 96

Issuer_PCP_ID ..................................................................................................................................................................................................................... 96

Record_Type ....................................................................................................................................................................................................................... 97

Appendix I: .................................................................................................................................................................................................................................. 98

A. QHP Network IDs for PY 2020 ............................................................................................................................................................................................ 98

B. QDP Network IDs for PY 2020 ............................................................................................................................................................................................ 99

Appendix II: ............................................................................................................................................................................................................................... 100

Covered California Rating Regions and Associated Counties ............................................................................................................................................... 100

Appendix III: Definition of terms used in this document ......................................................................................................................................................... 101

Appendix IV: Using the Provider Data Submission Guide for Application and Certification .................................................................................................... 103


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1.Revision History Date

Version Description Author

08/28/2015 1.0 • Initial Draft Ahmed Al-Dulaimi 09/09/2015 1.1 • Added Snapshot_Date Field

• Modified Year/Month_of_data to Last_Update Ahmed Al-Dulaimi

09/15/2015 1.2 • Added Record_Type Field to Header Record Layout • Added Record_Type Field to Detail Record Layout • Added Issuer_Provider_ID Field to Detail Record Layout • Added Issuer_PCP_ID Field to Detail Record Layout • Added Data_Start_Date Field to Trailer Record Layout • Added Data_End_Date Field to Trailer Record Layout • Added Record_Count Field to Trailer Record Layout • Added Record_Type Field to Trailer Record Layout

Ahmed Al-Dulaimi

09/17/2015 1.3 • Modified Record_Type Field in Header & Trailer Record Layout Ahmed Al-Dulaimi 11/09/2015 1.4 • Modified file format to CSV

• Removed start and end positions for data elements • Condensed Provider_Type and Facility_Type into 1 field and modified

acceptable values for new field • Added notes on Blanks, FTINs, Last_Update , names and special characters • Altered instructions on PCP_Flag to include any products with PCP

assignments.

Ahmed Al-Dulaimi

11/18/2015 1.5 • Removed field length specification in record • Modified wording for submission schedule

Ahmed Al-Dulaimi

11/23/2015 1.6 • Corrected value for Provider_Type field from “P” for professional only to “B” for both professionals and facilities on page 16

• Removed duplicate values from New Data Elements table on page 62 • Corrected Appendix B on page 66: Changed “O” for other to ”OF” for other

facility as an acceptable value for Provider_Type in the case of facilities. • Corrected Appendix C on page 68: Changed “O” for other to ”OI” for other

individual as an acceptable value for Provider_Type in the case of individuals.

Ahmed Al-Dulaimi

02/01/2016 1.7 • Added 2016 snapshot and submission schedule in part B of section 3. • Added clarification to submission schedule that any performance guarantees

would not apply to the initial cycles until layout is implemented in a satisfactory manner.

• Changed field names in part A of section 4, Header Record Layout to match field names in Detail Record Layout (Practice_Address to Location_Address, Practice_Address2 to Location_Address2 , Practice_Zip_Code to Location_Zip_Code, Practice_City to Location_City, Practice_County to

Ahmed Al-Dulaimi


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Location_County, Practice_Region to Location_Region, Practice_State to Location_State, Practice_Phone to Location_Phone)

• Modified instructions on using blanks instead of “U” for individual provider names in section 3.A

• Added note to section 6 clarifying that validation rules are for discussion and are not final “Note: The following rules are proposed for discussion only and are subject to revision.”

01/16/2017 1.8 • Modified Introduction section (now section 2) and included purpose, intended audience, and supporting documents.

• Added section on General Approach to Provider Data Quality (section 3) with subsections on Timeliness, Validity, Consistency, and Accuracy

• Modified Notes section to General Data Guidelines (section 4) • Removed Submission Schedule (will be a separate document) • Changed file format to Pipe Delimited TXT from CSV • Changed File Transmission Guidelines from Extranet to Issuer Hosted sFTP. • Removed requirement for Trailer record • Modified Section 4 Submission File Layout to be Section 5 • Corrected number of fields in Submission File Layout subsection A: Header

Record Layout from 71 to 70 • Removed section on Trailer records • Modified all detailed description tables in section 5 C to include more

clarifications and aditional instructions under the following subheaders: o Data Format and Type o Acceptable Values o Structural Validation o Relevance to Directory o Consistency o QHP FAQs o Authority Source

• Removed section 6 on Validation Rules (see section 3 C) • Removed section 7 on DMHC Mapping • Modified Appendix II from lookup tables to Rating Regions to Counties

crosswalk, III and IV • Modified Appendix III from lookup tables to Definition of Terms section • Added Appendix IV :Applying for 1st Time Certification, Re-Certification or

Offering New Products on the Exchange • Removed section XXXX • “Year/Month_of_Data” field label changed to “Last Update” • “Reserved” field changed to “Plan_Year”

Ahmed Al-Dulaimi

11/2017 1.9 • Updated Appendix I – QHP Network IDs for PY 2018 Margareta Brandt


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• Updated Supporting Documents section to indicate that the LexisNexis Data Dictionary and the Covered California Data Dictionary are separate documents. The LexisNexis Data Dictionary and ProviderPoint User Guide are now located on the Covered California Extranet.

• Fields 17 – 24: Changed all references from “Practice” to “Location” to be consistent throughout the Submission Guide

• Removed Location_Phone from Structural Validation process • Added details about the OSHPD ID structural validation check for QHPs with

100 or less facilities • Added information about the Invalid Visibility structural validation checks (for

provider types P, D, and H) • Removed Practice Phone Questionable from the Tier 1b discrepancy checks • Added Taxonomy code is not appropriate for provider type = P, D, and H to

Tier 1a discrepancy checks • Indicated Tier 2 errors - Physician Grouping by Taxonomy Classification Error

and PCP specialty is not typically associated with PCPs – will be removed from discrepancy checks in the future; Covered California has submitted a Change Request with LexisNexis to remove these checks

• Added details on the exclusion of certain hospital-based providers from the online directory. Covered California will exclude records where the primary specialty of the provider is one of these 5 classifications: hospitalist, emergency medicine, anesthesiology, pathology, and radiology.

• Updated the description for the Plan Year field to include detailed examples and a description of the process of transitioning between plan years

• Updated File Format and Naming Conventions to be more clear. Previously used CCYY to refer to the year. 'CC' refers to century and ‘YY' refers to year. Changed references from CCYY to YYYY.

• Added information about pre-processing checks and filters prior to Structural Validation

• Updated Appedix IV to provide more details about the differences between files for the Covered California Application and Certification process and the monthly data sumission files

1/2019 1.10 • Moved Data Element Description from Field No. 64 to Field No. 65. Melinda DeHerrera Rogers 9/2019 1.10 • General grammatical edits

• Updated document version to 1.10 on the title page • Updated Table of Contents to reflect page number change • Updated footer to read V 1.10 Q4 2019 • Updated URL for Attachment 14 • Updated PY reference on several pages


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• Updated Tier 1, Tier 2, and Tier 3 Discrepancy tables to mimic waterfall report o Removed: Physician Grouping by Taxonomy Classification Error* o Removed: PCP Specialty is not typically associated with PCPs* o Removed comment: *Covered California has submitted a Change

Request to remove Tier 2 discrpancies – Physician Grouping by Tezxonomy Classification Error and PC Specialty is not typically associated with PCPs – from the discrepancy reports.

• Updated QHP Network IDs • Updated QDP Network IDs • Updated Appendix II, alphabetized for ease of use • Updated Appendix III, alphabetized for ease of use


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2. Introduction Guided by its mission to improve the health of all Californians by assuring their access to affordable, high quality care, Covered California aims to provide its enrolled members with the best selection of high quality and affordable health plans. To that end, Covered California performs a rigorous review of all facets of participating plans which includes close inspection of networks and providers.

Covered California also aims to provide an informative and transparent shopping experience via tools that enable members to make informed decisions about their healthcare including provider choice which relies on accurate provider information. Ensuring the accuracy of provider information has always been a priority for Covered California due to the implications inaccuracies have on consumer choice, continuity of care and accurate representation of the products sold on the Exchange. For these reasons, Covered California requires its participating and prospective Issuers to provide complete information on their provider networks monthly.

Covered California also recognizes the general need for more accurate provider data in California. Because Covered California has 85% of all licensed active physicians and over 90% of all general acute hospital’s physicians in the state in one or more of its plans, its hope is to collaborate with all its participating Issuers, stakeholders, and partner agencies to improve the overall quality and accuracy of provider data in California.

Covered California’s goal is to assist Issuers in targeting errors in their source systems and in improving the quality of provider data overall, not solely for products offered through Covered California. Therefore, Covered California has employed the services of a third-party contractor, Lexis Nexis (LN), to provide data validation, cleansing and consolidation services via their ProviderPoint Solution. LN will compare data submitted by Issuers to LN’s proprietary Master Provider Referential database (MPRD) and conduct verification, de-duplication, correction, and augmentation of provider data.

Purpose of this Document The provision of complete, accurate and up to date provider information supports Covered California in its role as an active purchaser on behalf of its enrollees and stakeholders. This document is intended to assist Issuers in generating a comprehensive useable file containing complete network information to fulfill the contractual monthly provider data submission requirement for Covered California. This document contains the data standards, data attributes, and specifications necessary for building the required file in the correct format. It also contains details on Covered California’s effort to standardize and consolidate data from multiple Issuers into an online Multiplan Provider Directory. Specifically, this information supports:

• Covered California’s online Multiplan Provider Directory • Covered California’s network analyses including assessment of Essential Community Provider networks and access to quality care in

our most vulnerable communities • Assessment of Issuer networks for certification and rate negotiation purposes • Covered California’s Enhanced Enterprise Analytics Solution


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The 1st section of this document outlines Covered California’s general approach to data quality, the various ways this quality is assessed and how this assessment affects the monthly submission requirement and the online Multiplan Provider Directory display.

The 2nd section provides general guidance on generating and submitting the required monthly files including some general data concepts, file transmission rules, and communications.

The 3rd section details the data elements required in the file layout with the specific standards, authority sources, and business rules for populating each data element.

Intended Audience This document was designed with the following program areas in mind under the assumption that these are the two main program areas involved in generating the submission file and ensuring the correct information is provided to Covered California.

• Issuer Technical/IS Personnel: Charged with extracting, formatting and organizing the data from source (or other) systems. • Issuer Business/Policy/Operations/Regulatory Personnel: Charged with tracking and meeting business and regulatory requirements

and understanding the business rules and policy decisions that went into structuring the specifications. Also, charged with verifying discrepancy reports.

Issuers seeking to apply for certification or current Covered California Issuers seeking to offer new products should refer to Appendix IV for instructions on how to submit a certification-specific network file and apply for a new network ID.

Supporting Documents Covered California has compiled the following supporting documents to aid and support the completion of the provider data file submission. These documents can be found on the Covered California Extranet under “Provider Directory Resources”. Some documents are also posted to the Covered California HBEX website (noted below for applicable documents).

1. Covered California Provider Point User Guide: This document is intended to assist technical and non-technical personnel to navigate and make use of the feedback reports provided by LN to Issuers after every file submission.

2. LexisNexis Data Dictionary: This document includes many tabs with information relevant to the feedback reports Issuers receive from Covered California through LexisNexis.

a. Detail Error Report Layouts and Client Integration Codes: Multiple tables containing decodes and explanations to help navigate and make use of the detail discrepancy reports provided by Covered California as part of its accuracy check.

3. Covered California Data Dictionary: This document includes many tabs with tables, references, descriptions, and crosswalks. Of importance are the following tabs:

a. Covered California Provider Type – NUCC Specialty Taxonomy Crosswalk: A useful crosswalk of Provider Type, Specialty Taxonomy and Type of Service codes in addition to descriptions of every specialty, sub-specialty and classification. The list of

https://planmanagement.coveredca.com/Resources/Forms/AllItems.aspx?RootFolder=%2FResources%2FProvider%20Directory%20Resources&FolderCTID=0x012000F49E8E5D01059E46B470CE5C2932DBA3&View=%7BF8874555%2DB973%2D41D6%2D9F92%2DD5235DDEF936%7Dhttp://hbex.coveredca.com/stakeholders/plan-management/


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specialty taxonomy codes is issued and maintained by the National Unified Claims Committee and augmented by Covered California. This list is usually updated twice annually, in January and July of each year.

b. Covered California Facility Reference List (OSHPD List): This list includes all facilities monitored by the Office of Statewide Health Planning and Development.

c. ISO 639 – 2 & 3 Code list: Table of codes for most written languages. 4. Covered California ECP reference list: A single, non-duplicated list of Essential Community Providers (ECPs) that potentially could

serve Covered California enrollees; the list is updated annually prior to the Covered California Application and Certification period. This can be found on the Covered California HBEX website.

5. Provider Data Submission Schedule: Submission schedule for plan year (PY) 2020 includes “extract by” and “submit by” dates. Questions on the information contained in this document should be directed to the following email address: [email protected]

Back to Contents

http://www.nucc.org/http://hbex.coveredca.com/stakeholders/plan-management/ecp-list/mailto:[email protected]


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3. General Approach to Provider Data Quality

Covered California attempts to assess the quality of Issuer supplied provider data in four main domains:

A. Timeliness: Timely Submission and Recentness of data B. Validity (Completeness): Usability of the submitted file, Percentage of missing information in critical fields C. Consistency: Reasonability of the data, zoomed out look at the data vs each individual element D. Accuracy: How closely the data reflect the actual world

A. Timeliness and Recentness of

Submitted Data

B. Validity and Completeness of Submitted Data

C. Consistency and Reasonability of Submitted Data

D. Accuracy of Submitted Data

Provider Data Quality

• Is the submitted file complete? • Do the critical fields have an excess of

blanks? • Are there any transposed fields? • Is the file in the correct file format?

• Does the data make sense when considered as a whole?

• Are the frequencies of different provider types or specialties typical of this network type?

• Does it stand up to statistical scrutiny?

• Was the data extracted from the source system on the correct date?

• When was the last time this data was updated?

• Was the monthly data submitted by the deadline?

• Is the submitted data accurate to the real world?

• When and how was the information received and validated?

• Are there critical errors in the information?


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A. Timeliness: • Covered California requires participating Issuers to submit provider data monthly per the Provider Data Submission Schedule

described in the Supporting Documents section. • Adherence to this schedule enables timely processing and display of provider data on the Covered California online Multiplan

Provider Directory. • This data should be “cut” or extracted no earlier than the last day of the preceding month to ensure a degree of freshness to the

data. • Covered California expects that Issuers ensure minimal time between receiving a reported change to a provider’s contract, location or

demographics, and its eventual display on an online directory and submitted file as specified in CA Senate Bill 137. • While Covered California does not have purview over the internal reporting and updating process, Covered California does track the

timeliness of submitted files and applies a performance guarantee for non-timely submissions. For details, please refer to section 2.5 of Attachment 14 of the QHP Model Contract available here.

• Covered California will consider a submission timely if the Issuer submits a valid file by end of day (EOD) on the predefined deadline. See below for details on how structural validity of files is assessed.

The monthly submission cycle through data cleansing and online display is detailed in Table 1 below for any typical month. Issuers must deposit the monthly submission file in the specified repository (see section on File Transmission for details) by EOD on the 7th business day of any given month (barring holidays and other events that occur on the 7th business day).

Business Day Duration Activity Last Business Day of Prior Month

NA QHP Issuer pulls provider data as of last day of month

1 – 7 7 QHP Issuer prepares Covered California Provider Data Submission File

7 NA QHP Issuer submits Covered California Provider Data File to Issuer hosted sFTP by EOD on Day 7

8 1 LexisNexis conducts structural validation and uses last successful file (


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Issuers submitting before the deadline can re-submit files up to the deadline if there is a problem with the file structure or structural validation causing a failed submission. If an Issuer fails to submit a structurally valid file by the deadline or if the submitted file fails validation with no valid substitute by the deadline, Covered California will resort to the last useable file submitted by the Issuer if that file is less than 3 months old. If the last usable file is more than 3 months old, an Issuer’s provider data will be omitted entirely from the online display.

B. Validity (Completeness): This pertains to the Structural Validity of the incoming files and aims to ensure their usability. Covered California has created a process whereby each incoming file submission from participating Issuers is subjected to a structural validation process to ensure usability of the submitted file for the accuracy checks and consolidation required for integration into the online Multiplan Directory. This process primarily addresses inappropriate blanks and missing data in critical fields (see Table 2) in addition to transposition of fields and other structural aspects of the file. Structural validation will be initially assessed only for Physicians, Dentists, and Hospitals (Provider Types P, D and H). Prior to checking files for structural validation, Covered California will filter incoming files for Individual market Network IDs and Provider Types P, D, and H. For dentists (Provider Type = D), Covered California will only assess structural validation if the Type of Licensure field is populated with DDS. Dentists with other types of licensure will be filtered out prior to the structural validation process and will not be displayed in the online directory.

# Field All or Subset of Providers?

1 Provider_Type All (P, D and H) 2 First_Name Subset (Provider_Type = P, D) 3 Last_Name Subset (Provider_Type = P, D) 4 OSHPD_ID Subset (Provider_Type = H) 5 Location_Address All (P, D and H) 6 Location_City All (P, D and H) 7 Location_State All (P, D and H) 8 Location_Zip_Code All (P, D and H)

9 Primary_Specialty Subset (Provider_Types = P, D) 10 Network_ID All (P, D and H) 11 Accepting_New_Patients All (P, D and H) 12 Plan_Year All (P, D and H) 13 Invalid Visibility (P) Subset (Provider_Type = P) 14 Invalid Visibility (D) Subset (Provider_Type = D) 15 Invalid Visibility (H) Subset (Provider_Type = H)

Table 2: Data fields subject to structural validation


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• If 1% or greater of all input records are blank for any one of the above fields or if the input file does not match the number of

columns in the input file layout, the Issuer’s input file will be rejected. The rejected record counts and reason will be part of the communication. Other fields may be added as necessary to this validation step.

• If less than 1% of all input records are blank for any one of the above fields, the Provider Data Submission file will be processed and the record will be returned in the Detail Discrepancy File. Fields with blanks will be omitted entirely from the online display.

• For the OSHPD ID structural validation check, if 1% or greater of all input records for QHPs with 100 or more facilities are blank or have unacceptable “X” or “U” values, the input file will be rejected. If the QHP has 100 or less facilities, one invalid OSHPD ID will be allowed. If more than one invalid OSHPD ID is found, the input file will be rejected.

• For the Primary Specialty, in addition to checking for the unacceptable values of blank, “X” or “U”, the structural validation check includes validation that the taxonomy code is 10-characters with the first three characters being numeric, next six being alpha and/or numeric and last character = X with a field length = 10.

• The Invalid Visibility structural validation checks ensure that an Issuer’s entire file is not set to Visibility = No. An input file will only fail if the Visibility field = No for 100% of provider types P, D or H.

• Failing structural validation has implications for representation on the online directory as discussed above in the section on timeliness. 1. If an Issuer fails to submit a structurally valid file by the deadline or if the submitted file fails validation, Covered California will

resort to the last useable file submitted by the Issuer if that file is less than 3 months old. 2. If the last usable file is more than 3 months old, an Issuer’s provider data may be omitted from the online display. The

communication process for all such events is detailed below in Section 5. • Issuers can re-submit files up to the deadline if there is a problem with the file structure or structural validation causing a failed

submission.


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Figure 2. Structural Validation and File Acceptance Criteria

Figure 2 shows the process workflow for structural validation and file acceptance/rejection.

LexisNexis File Watcher pulls file from sFTP Issuer deposits file in Issuer hosted sFTP

LexisNexis conducts structural validation on

file


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C. Consistency (Reasonability): This pertains to the quality of the data taken beyond the individual element. After ensuring the validity of the individual data elements, the data in its entirety must be plausible and reasonable as a whole. For e.g., a file may be timely, contain no blanks but when analyzed, has a distribution of physician specialties that falls outside the expected or typical distribution of specialties of a similar network or the primary care to specialty care physician ratios may be outside expected norms for the network type. If this is the case, further analysis of the data set may be warranted. Covered California conducts several tests on the consistency of a submitted dataset against the following parameters. Some of these are assessed and reported in the Discrepancy Reports (see Section 3.D. or the ProviderPoint User Guide available on the Covered California Extranet under “Provider Directory Resources” for details). The majority, however, will be assessed and reported separately.

# Consistency Validation 1 Anesthesiologist address does not match an in-network hospital address

2 Hospitalist address does not match an in-network hospital address (see glossary for definition of Hospitalist) 3 Distribution of physician specialties is unexpected or not typical for network type 4 Physician affiliated hospitals must be in-network

5 Hospital must have adequate number of physicians able to admit to that hospital in the network and in reasonable proximity

6 Lower tiered hospitals in the network should have a reasonable number of affiliated physicians so that patients are not obligated to use a higher tiered hospital due to physician affiliation 7 Percentage of providers accepting new patients 8 Discrepancy in reported specialty across issues 9 Physician does not have admitting rights to an in-network hospital

10 Hospital does not have physicians able to admit to it in the network 11 Percentage of board certified physicians 12 Ratio of primary care to specialist physicians outside norms for network type 13 PCP specialty is not typically associated with PCPs

14 Physician or dentist has numerous active locations - Based on the number and geographic spread of locations it is unrealistic that a provider truly practices at all locations

15 Physician or dentist has a location in a non-adjacent County - Individual provider has multiple active locations located in non-adjacent counties or locations that are significantly distant from each other Table 3: Possible checks for consistency (reasonability) validation

https://planmanagement.coveredca.com/Resources/Forms/AllItems.aspx?RootFolder=%2FResources%2FProvider%20Directory%20Resources&FolderCTID=0x012000F49E8E5D01059E46B470CE5C2932DBA3&View=%7BF8874555%2DB973%2D41D6%2D9F92%2DD5235DDEF936%7D


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D. Accuracy: This pertains to how closely submitted data mirrors the actual real world status of the networks it purports to represent. Ensuring accuracy has always been a top priority for Covered California due to the implications inaccuracies have on consumer choice, continuity of care and providing a clear representation of Issuer products. To assess accuracy, LN provides a data cleansing and consolidation service via their ProviderPoint Solution to compare data submitted by Issuers to the LN’s proprietary Master Provider Referential database (MPRD) and conduct verification, de-duplication, correction, and augmentation of provider files. Please refer to the ProviderPoint User Guide available on the Covered California Extranet under “Provider Directory Resources” for details.

Covered California has classified accuracy errors into three distinct tiers depending on their severity and impact on the consumer shopping experience as follows:

Tier 1 Discrepancies: These are high priority potential errors that could severely impact and undermine consumer choice. Covered California will suppress provider records with discrepancies in this category until resolved or verified to be accurate. The table below lists all the Tier 1 discrepancy types and the corresponding client integration code (the code you use to find the specific provider records with these discrepancies in the Detail Discrepancy File.)

Tier 1 - High Priority Critical Discrepancy- Significant Member Impact Code

1 Provider Status Reported Deceased U 2 Provider Status Retired R1, R2 3 License Expired I, K 4 Federal OIG/LEIE Sanction Y 5 Federal OPM Sanction Y 6 OSHPD ID is not valid or does not appear on reference list - facilities only Y 7 OSHPD ID type of service does not match type of service field - facilities only Y 8 Practice Address inactive, update available GD, GN, II 9 Practice Address inactive, no update available IR

10 Practice Address inactive and inactive/suspended license Z 11 Practice Address is PO Box P 12 Taxonomy code is not appropriate for provider type = P = (taxonomy 20) Y 13 Taxonomy code is not appropriate for provider type = D = (taxonomy 12) Y 14 Taxonomy code is not appropriate for provider type = H = (taxonomy 28) Y 15 No match input records Y



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Tier 2 Discrepancies: These are potential errors that could lead to some consumer confusion and therefore need to be flagged, investigated and verified but will not be suppressed from online display. The table below lists all the Tier 2 discrepancy types and the corresponding code.

Tier 2 - Medium Priority Discrepancy - member confusion (record counts) Code

17 Practice Phone verified inactive, update available G 18 Practice Phone verified inactive, no update available I 19 Practice Phone questionable, update available E 20 Practice Phone questionable no update B, M, J 21 Restrictive Sanction in practice state Y 22 Provider Name potentially transposed CT 23 Provider Name matched to "Formerly Known as Name" F 24 Male/Female Identification A 25 Practice Address is undeliverable X 26 Practice Address is inactive (lower confidence than tier 1 inactive addresses) I2 27 Practice Address – High Risk – Address matches to a non-postal secondary range. N 28 License Suspended in a state (may not be practice state) 8 29 License Unverified, augmentation available in practice state L 30 License Blank – no augmentation M 31 License belongs to different provider, augmentation available Q 32 License unverified – augmentation available NOT in practice state T 33 License Blank – augmentation available NOT in practice state W 34 License Expired – active license augmentation available in practice state G


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Tier 3 Discrepancies: These are potential errors that are not expected to impact the consumer plan selection experience but need to be flagged to improve the overall integrity of the data and to improve provider data consolidation from multiple Issuers into one record per provider per location. The table below lists all the Tier 3 discrepancy types and the corresponding code.

Tier 3 - Low Priority Discrepancy Code 36 NPI Correction Available 1, Q, S, A, L, G 37 NPI Unverified or bad format, doesn't pass checksum; no augmentation Blank, B 38 NPI input blank; bad or unverified; only NPI found is deactivated; checksum fail F, I, M 39 NPI Type 1 or Type 2 mismatch; no augmentation 2 40 NPI Deactivated D1, D2 41 Rating Regions not aligned with county zip code combinations Y

Covered California will exclude all Tier 1 errors from online display. As detailed above, these are the errors most likely to cause a significant impact to the consumer experience and mislead consumers during the critical plan selection phase of enrollment. Information containing these types of errors will remain suppressed until resolved or verified to be accurate. Details on how Issuers can provide feedback and dispute errors with Covered California are detailed in the User Guide for Provider Data Discrepancy Review available on the Covered California Extranet under “Provider Directory Resources”.

Information with Tier 2 and Tier 3 errors will not be excluded from the online display with the understanding that these errors may contribute to consumer confusion and should be addressed in a timely manner by the submitting Issuer. The focus initially should be resolving the flagged Tier 1 errors.

Covered California will assess accuracy of provider information every cycle by comparing the incoming input file with the ProviderPoint referential database and generate the following accuracy related reports:

1. Waterfall Report: Summary view of the discrepancies identified by ProviderPoint in the QHP’s provider data submission file 2. Discrepancy Reports:

a. Detail Discrepancy Report: Record level detail about the discrepancies as summarized in the Waterfall Report b. Simple Discrepancy Report: Same content as the Detail Discrepancy report except that data is organized with each Tier 1

discrepancy type in its own tab containing only the necessary fields to review and verify the discrepancy c. Tier 2 and 3 Simple Discrepancy Report: Simple Discrepancy Report for Tier 2 and Tier 3 discrepancies

3. Address Phone Fax Report: Detailed file that includes additional address, phone and/or fax numbers (to be used for potential phone or fax corrections)

4. Net New Address Report: Condensed version of the Address Phone Fax Report that contains only “new addresses” (to be used for potential address corrections)

5. Board Sanction: Provides Federal and State Medical Board sanction details on the providers identified as having sanctions Back to Contents



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4. General data guidelines when creating and submitting file(s) A. Dealing with missing, unknown or non-applicable values

• All fields are required if they apply. • If the information exists on the Issuer’s online directory, the expectation is that it will be provided to Covered California. • Blanks are only permissible if data does not apply to the provider type. An example of this is when it applies to any of the name fields

for individual providers: it is permissible to enter First_Name and Last_Name as null for Provider_Type H (Hospitals). These are situational fields i.e. certain elements apply only to certain provider types. Please refer to the “Detailed Definitions and Specifications of Data Elements”, Section 5 of this document, for details on situational data elements.

• “Other” is never an acceptable value.

B. Data Formats, Data Types and Standardizations • For the purposes of online display, Covered California will standardize the information it receives from the various participating

Issuers to the best available authority source. This is vital to ensure adequate consolidation of this data to the goal of one provider per location per row.

• Data element names must be submitted exactly as specified by Covered California if a reference is provided. Alternate or abbreviated names will not be accepted. All provider names will ultimately be standardized for online display.

• Covered California provides several reference lists and crosswalks to create a more standardized controlled input. In addition, there are many data fields in the layout that require a specific data input type. Some of the main data types used in creating the submission file are:

o Coded Text: these fields derive their value from a code table with each acceptable value and its meaning. These tables or lists are available as appendices or in one of the companion documents to this guide e.g., the Covered California Data Dictionary.

o Integers: exact integral numeric values (e.g., number of assigned enrollees). o Unique Identifier: these fields contains various alpha numeric identifiers for individual elements. o Numeric Strings o Text: character strings (with optional language). Unless otherwise constrained by an implementation, can be any combination

of alpha, numeric or symbols from the Unicode character set. Sometimes referred to as free text. o Boolean: these fields have 1 of 2 acceptable values, usually Y or N, X or null, etc. and represent a simple “true” vs “false”

switch. o Date: must be in MM/DD/YYYY format.

C. Row counts, row duplications and included provider types • Within a provider network for each product, Issuers should limit the number of records per provider to the number of locations for

the provider, i.e. if a provider practices in 5 locations it is permissible to list each location as a separate row. However, duplicating records per provider for other data elements such as phone number is discouraged; the best phone number should be chosen for


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each location listed for the provider. Similarly, the best three languages for the provider should be chosen and no rows per provider should be duplicated by language (if a provider speaks more than three languages). The same applies to other data elements.

• Dental providers included in the Issuer’s provider network offering as part of the embedded pediatric dental benefit should be included in the QHP Issuer’s input file. Dentists should be marked as Provider_Type = D.

o Covered California will only assess structural validation if the Type of Licensure field is populated with DDS for records where Provider_Type = D. Dentists with other types of licensure will be filtered out prior to the structural validation process and will not be displayed in the online directory.

• Issuers should include all network providers in the input file and ensure that all provider locations available to Covered California enrollees are included in the input file.

• Currently certified QHP Issuers and new entrant applicants seeking to use this guide to create a submission file for the purpose of annual certification must, to the extent possible, depict networks for the year they are seeking certification for, not for the current plan year (PY). For example, a current Issuer applying for certification for PY 2021 must submit a file depicting 2021 networks during the certification period which occurs mid-2020. For monthly provider data submissions, Issuers must submit current data for their provider networks. See Appendix IV for details.

• Special attention is recommended when submitting a file for the annual open enrollment period. Issuers should indicate whether a provider is available in the Issuer’s network for the current and upcoming PY using the Plan_Year field. For example, if a provider’s contract ends on December 31st of the current PY, the Issuer should list the provider as only available in the current PY and not available in the future PY. Please see Section 5 for more details on indicating provider availability for each year.

D. File Format and Naming Conventions The data should be submitted as a pipe delimited text file. This format will enable use of special characters in the content of the submitted file and reduce the need to scrub the input files for commas and other common characters used in names, addresses, etc. Issuers must use the following file naming standard for the input files submitted to Covered California.

File Naming Convention

Medical Provider Roster Files MM_YYYY_ISSUERID_QHP_CC.TXT

Dental Provider Roster Files MM_YYYY_ISSUERID_QDP_CC.TXT

ISSUERID = Issuer HIOS ID number. Refer to Appendix I for a list of the HIOS numbers for currently participating QHP and QDP Issuers. MM_YYYY = Month and year of submission due date as specified by Covered California.

Example: 06_2020_12345_QHP_CC.TXT Variation from this naming standard may result in file rejection in the automated file transmission process described in the next section. Please note that Trailer records are no longer required as part of the input file and should not be included in the submission.


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E. File Transmission Guidelines Each participating Issuer is required to submit a monthly input file containing complete network data according to the specifications defined in this document. To ensure a timely and smooth submission process, Covered California requires each participating Issuer to set up and host a Secure File Transmission Protocol (sFTP) site with an inbound and outbound directory. Access must be granted to Covered California to “push and pull” files to and from the sFTP. Covered California will automatically retrieve monthly submissions from the outbound directory every month and deposit any reports or feedback files to the inbound directory. Participating QHPs and QDPs must provide:

• sFTP URL • sFTP login information • Inbound and Outbound directories

Please whitelist the following LexisNexis Public IP Addresses (LN): 64.73.140.185, 209.243.55.184

F. Communications between Covered California and Participating Issuers Effective and timely communication is essential for the success of the online Multiplan Provider Directory. Each participating Issuer must notify Covered California via email when a file has been deposited on the Issuer-hosted sFTP. Covered California will send communications to Issuers when:

• The Issuer fails to submit a file by the deadline and a usable file from the Issuer is available that is less than 3 months old, notifying the Issuer that the last usable file will be used for the directory.

• The Issuer fails to submit a file by the deadline and a usable file from the Issuer is not available (more than 3 months old), notifying the Issuer that no provider data will be included in the online directory for the cycle.

• A file fails structural validation and is rejected with the option to resubmit up to the identified deadline. • A file fails structural validation and is rejected without the option to resubmit and where a usable file from the Issuer is available that

is less than 3 months old, notifying the Issuer that the last usable file will be used for the directory. • A file fails structural validation and is rejected without the option to resubmit and where a usable file from the Issuer is not available

(more than 3 months old), notifying the Issuer that no provider information will be included in the directory for the cycle.


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Figure 03. Communications during file validation

Back to Contents

LexisNexis File Watcher pulls file from sFTP Issuer deposits file in Issuer hosted sFTP

LexisNexis conducts structural validation on

file


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5. Submission File Layout The file should consist of two portions: A header row and a number of detail rows. Each portion is described in the sections below.

A. Header record data elements The header record contains the names of the fields that make up the detail records.

Field No. Data Element Header Names

Note

1 Last_Name 1st record only

2 First_Name 1st record only

3 Middle_Name 1st record only

4 Provider_Type 1st record only

5 NPI 1st record only

6 CA_License 1st record only

7 Non_CA_License 1st record only

8 Non_CA_License_State 1st record only

9 Provider_Gender 1st record only

10 Provider_Language_1 1st record only



13 Facility_Language_1 1st record only



16 Type_of_Licensure 1st record only

17 Location_Address 1st record only

18 Location_Address_2 1st record only

19 Location_Zip_Code 1st record only

20 Location_City 1st record only

21 Location_County 1st record only

22 Location_Region 1st record only

23 Location_State 1st record only

24 Location_Phone 1st record only

25 Provider_Clinic_Name 1st record only


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Note

26 Provider_Clinic_ID 1st record only

27 Primary_Specialty 1st record only

28 Secondary_Specialty 1st record only

29 Board_Certified 1st record only

30 Medical_Group/IPA_1 1st record only




34 Contract_Type 1st record only

35 Hospital_1 1st record only




39 Hospital_1_OSHPD_ID 1st record only




43 Hospitalist_(Hosp_1) 1st record only




47 NPI_Sup_PCP 1st record only

48 Sup_PCP_Specialty 1st record only

49 DEA 1st record only

50 Facility_Name 1st record only

51 Facility_System 1st record only

52 OSHPD_ID 1st record only

53 Type_of_Service 1st record only

54 Tertiary_Care 1st record only

55 FTIN 1st record only

56 Last_Update 1st record only


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Note

57 Plan_Year 1st record only

58 Current_Assigned_Enrollees 1st record only

59 PCP_Flag 1st record only

60 Network_ID 1st record only

61 Network_Tier_ID 1st record only

62 Availability 1st record only

63 Visibility 1st record only

64 Covered_California_ID 1st record only

65 ECP_Flag 1st record only

66 Accepting_New_Patients 1st record only

67 Snapshot_Date 1st record only

68 Issuer_Provider_ID 1st record only

69 Issuer_PCP_ID 1st record only

70 Record_Type 1st record only


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B. Detail Record Data Elements The following specifications pertain to the detail record portion of the submitted set and represent all records between the header and the trailer.

Field No. Field Name

Max Lgth Format

Type Data Element Description

Facility Indiv Both

1 Last_Name 50 Char Text Last name of provider I 2 First_Name 50 Char Text First name of provider I 3 Middle_Name 50 Char Text Middle initial of provider I

4 Provider_Type 2 Char

Coded Text Indicates type of individual provider: Physician = P Dental Provider = D Physician Extender = PE Other Individual Provider = OI Hospital = H Clinic = C Other Contracted Provider Facility = OF

B

5 NPI 10 Num Unique ID National Provider Identification (NPI) number of the individual B 6 CA_License 15 Char Unique ID California License number, applies to all providers and facilities B 7 Non_CA_License 15 Char Unique ID License number for non-CA licensed/Out of state providers B 8 Non_CA_License_State 2 Char Coded Text License state for non-CA licensed/Out of state providers B 9 Provider_Gender 1 Char Boolean Gender of the Provider I

10 Provider_Language_1 20 Char Coded Text 1st Language spoken by the provider other than English I 11 Provider_Language_2 20 Char Coded Text 2nd Language spoken by the provider other than English I 12 Provider_Language_3 20 Char Coded Text 3rd Language spoken by the provider other than English I

13 Facility_Language_1 20 Char Coded Text Language spoken by an individual employed at the provider's office or facility but not spoken by the provider other than English I



16 Type_of_Licensure 5 Char Coded Text e.g., MD, DO for physicians - Refer to lookup table for remainder of licensed medical professions in CA I

17 Location_Address 35 Char Text 1st line street address for provider or facility location B 18 Location_Address_2 10 Char Text 2nd line street address for provider or facility location B 19 Location_Zip_Code 5 Num Numeric string 5-digit zip code of provider or facility location B 20 Location_City 25 Char Text City of provider or facility location B 21 Location_County 25 Char Text County of provider or facility location B 22 Location_Region 2 Num Coded Text Covered California rating region of provider or facility location B 23 Location_State 2 Char Coded Text State of provider or facility location B 24 Location_Phone 12 Char Phone number of provider or facility location B 25 Provider_Clinic_Name 50 Char Text If individual provider works at a clinic, enter the clinic name I 26 Provider_Clinic_ID 16 Char Unique ID If individual provider works at a clinic, enter the clinic ID I

27 Primary_Specialty 10 Char

Coded Text Primary specialty of the provider. In case of physicians, this must be highest/latest certification received by the provider, e.g. Neonatologist with a specialty in Pediatrics should be listed as Neonatologist unless it is explicitly known that provider practices primarily as a Pediatrician.

B


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Max Lgth Format


Facility Indiv Both

28 Secondary_Specialty 10 Char Coded Text Secondary specialty of the provider. Should be populated when provider has secondary/base specialty. B

29 Board_Certified 1 Char Coded Text Board certified, eligible or non-certified indicator I

30 Medical_Group/IPA_1 50 Char Text Name of first medical group and/or IPA affiliated with contracted provider (if applicable) I

31 Medical_Group/IPA_2 50 Char Text Name of second medical group and/or IPA affiliated with contracted provider (if applicable) I

32 Medical_Group/IPA_3 50 Char Text Name of third medical group and/or IPA affiliated with contracted provider (if applicable) I

33 Medical_Group/IPA_4 50 Char Text Name of fourth medical group and/or IPA affiliated with contracted provider (if applicable) I

34 Contract_Type 2 Char Boolean Delegated vs. Direct Contract B

35 Hospital_1 50 Char Text Name of the first hospital with which the provider holds admitting privileges I

36 Hospital_2 50 Char Text Name of the second hospital with which the provider holds admitting privileges I

37 Hospital_3 50 Char Text Name of the third hospital with which the provider holds admitting privileges I

38 Hospital_4 50 Char Text Name of the fourth hospital with which the provider holds admitting privileges I

39 Hospital_1_OSHPD_ID 10 Char Coded Text OSHPD ID Number for the first hospital with which the provider holds admitting privileges I

40 Hospital_2_OSHPD_ID 10 Char Coded Text OSHPD ID Number for the second hospital with which the provider holds admitting privileges I

41 Hospital_3_OSHPD_ID 10 Char Coded Text OSHPD ID Number for the third hospital with which the provider holds admitting privileges I

42 Hospital_4_OSHPD_ID 10 Char Coded Text OSHPD ID Number for the fourth hospital with which the provider holds admitting privileges I

43 Hospitalist_(Hosp_1) 1 Char Boolean Hospitalist Indicator for the first hospital with which the provider holds admitting privileges I

44 Hospitalist_(Hosp_2) 1 Char Boolean Hospitalist Indicator for the second hospital with which the provider holds admitting privileges I

45 Hospitalist_(Hosp_3) 1 Char Boolean Hospitalist Indicator for the third hospital with which the provider holds admitting privileges I

46 Hospitalist_(Hosp_4) 1 Char Boolean Hospitalist Indicator for the fourth hospital with which the provider holds admitting privileges I

47 NPI_Sup_PCP 10 Char Unique ID National Provider Identification (NPI) number of the Supervising provider in case of PCP extenders I

48 Sup_PCP_Specialty 10 Char Coded Text Supervising Providers primary specialty I 49 DEA 12 Char Provider Drug Enforcement Administration (DEA) Number I

50 Facility_Name 50 Char Text Legal name of facility utilized by the Plan.

In case of hospitals, use name exactly as listed on the Covered California Reference list.

F

51 Facility_System 50 Char Text Health system of facility F 52 OSHPD_ID 10 Char Unique ID In case of hospitals, use as per Covered California OSHPD ID list. F 53 Type_of_Service 5 Char Coded Text Type of Service as defined by the Facility Type F 54 Tertiary_Care 1 Char Boolean Tertiary Care Indicator F 55 FTIN 9 Char Unique ID The federal tax ID of the provider B 56 Last_Update 10 Char Date Last time provider data updated B


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Max Lgth Format


Facility Indiv Both

57 Plan_Year 4 Num Coded Text Year available B

58 Current_Assigned_Enrollees 6 Num Numeric String For Primary Care Clinics & Primary Care Physicians: the total number of patients assigned to the provider B

59 PCP_Flag 1 Char Boolean Provider or Clinic is designated as PCP by issuer B

60 Network_ID 11 Char Alphanumeric String Network ID assigned by Covered California B

61 Network_Tier_ID 1 Num Coded Text Network Tier ID B 62 Availability 1 Char Boolean Available directly or with special authorization/referral B 63 Visibility 1 Char Boolean Indicates whether provider is to be displayed on online directory B 64 Covered_California_ID 16 Char Unique ID Used to flag ECP providers F 65 ECP_Flag 1 Char Boolean Used to flag ECP providers B 66 Accepting_New_Patients 1 Char Boolean Accepting New Patients Indicator B 67 Snapshot_Date 10 Char Date Date of data extraction for file B 68 Issuer_Provider_ID 35 Char Unique ID Issuer assigned provider ID B 69 Issuer_PCP_ID 35 Unique ID Issuer assigned primary care provider ID I 70 Record_Type 1 Char Hardcoded Type of Record: D for Detail (non-Header and non-Trailer records) B


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C. Data Element Detail Descriptions In this section, each data element will be discussed in detail under the context of the following headers:

Header Description Technical Specifications

Definition Description of the data element

Applicable to

Determines which provider type this data element is relevant to. • Facility Providers, including Hospitals “H”, Clinics “C” or Other Types of Facilities “OF”. • Individual Providers, including Physicians “P”, Dental Providers “D”, Physician Extenders “PE” Certain data elements will only apply/be required for a subset of individual or facility providers.

Max Length The maximum length a value may have in this field. Values may be equal or less than this number in length.

Data Format and Type The type of data, either character (Char) or numeric (Num). Data Type is a classification that specifies which type of value a variable has and what type of operations can be applied to it. e.g., Date is a data type that is used to classify date values.

Acceptable Values/Data Value Domain

Description of all acceptable input values for this data element if applicable. Controlled terminology vs non-controlled terminology.

Structural Validation States if the data element is assessed for structural requirements in the preprocessing validation step, i.e., are there excessive null values in fields critical to the online directory. Business Context/Specifications

Relevance to Multi-Plan Directory Description of relevancy of this data element to Covered California’s Multiplan Directory. Also, specifies if element is visible and/or searchable to consumers online.

Authority Source

Many data elements are issued by or can be obtained from certain authority sources which are typically the issuing agencies or reliable and verified sources for the data. QHPs will be the authority source for some data elements such as Network ID, Panel Status and other elements defined by contract between the Issuer and the provider.

Consistency and Accuracy Validation

Description of the validation checks performed on this data element. This can consist of two main types of validation: • Consistency Validation: data elements are assessed for consistency across the file (e.g., we

would expect Last Name and First Name inputs for individual providers). • Accuracy: data elements are checked for accuracy against a Master Provider Referential

Database. LexisNexis currently provides this service to Covered California.

QHP FAQs Miscellaneous notes, tips, and additional information to assist in the successful submission of the data element.


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Last_Name Technical Specifications

Definition The last name of an individual provider contracted with the health plan to provide services to enrollees Applicable to Individual Providers only (where Provider_Type = “P”,”D”,”OI”, “PE”) Max Length 50 Format / Type Char / Text Acceptable Values 1. Must be full name and not initials

2. “U” and “X” are not acceptable values for provider types “P”, “D”, “OI” and “PE” and will not be taken to indicate “Not applicable” or “Unknown”

3. Field should be left blank for provider types “H”, “C” and “OF” Structural Validation Structural validation will be performed on individual providers with provider type = “P” and “D” “U” and “X” are acceptable

values for provider types “P” and ”D” Business Context / Specifications

Relevance to Multi-Plan Directory

1. Critical to the search and identification of individual providers (with provider types “P”, “D”) 2. Visible to consumers and searchable online.

Authority Source/Data Standard

1. Medical Board of California: Covered California will standardize the last name to the name on the MBC license. Medical Board license info can be found at http://www.mbc.ca.gov/

2. Osteopathic Medical Board of California: Covered California will standardize last name to name on the OMBC license. Medical Board license info can be found at http://www.ombc.ca.gov/

3. Other provider types will be verified against their respective licensing board information. General information on licensing boards in California can be found at the Department of Consumer Affairs’ website at http://www.dca.ca.gov

Data Consistency & Accuracy Validation

1. For provider types “P” and “D”, Last Name will be standardized based on the name found in the authority source, if the provider has a California License.

2. Transposition error: Names are checked for potential transposition with transposed names flagged in the detail result file. Please refer to the User Guide for Provider Data Discrepancy Review for more details on how to locate this discrepancy in the Detail Discrepancy File

3. “Formerly known as” validation: Input names are matched to “Formerly Known As” field in NPPES or DEA database. Formerly known as names are flagged in the detail result file. Please refer to the User Guide for Provider Data Discrepancy Review for more details on how to locate this error.

QHP FAQs Examples

http://www.mbc.ca.gov/http://www.ombc.ca.gov/http://www.dca.ca.gov/


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First_Name Technical Specifications

Definition The first name of an individual provider contracted with the health plan to provide services to enrollees Applicable to Individual Providers only (where Provider_Type = “P”,”D”,”OI”, “PE”) Max Length 50 Format / Type Char / Text Acceptable Values 1. Must be full name and not initials

2. “U” and “X” are not acceptable values for provider types “P”, “D”, “OI” and “PE” and will not be taken to indicate “Not applicable” or “Unknown”

3. Field should be left blank for provider types “H”, “C” and “OF” Structural Validation Structural validation will be performed on individual providers with provider type = “P” and “D” “U” and “X” are acceptable

values for provider types “P” and ”D” Business Context / Specifications

Relevance to Multi-Plan Directory

1. Critical to the search and identification of individual providers (with provider types “P”, “D”) 2. Visible to consumers and searchable online

Authority Source/Data Standard

1. Medical Board of California: Covered California will standardize the first name to the name on the MBC license. Medical Board license info can be found at http://www.mbc.ca.gov/

2. Osteopathic Medical Board of California: Covered California will standardize first name to name on the OMBC license. Medical Board license info can be found at http://www.ombc.ca.gov/

3. Other provider types will be verified against their respective licensing board information. General information on licensing boards in California can be found at the Department of Consumer Affairs’ website at http://www.dca.ca.gov

Data Consistency & Accuracy Validation

1. For provider types “P” and “D”, First Name will be standardized based on the name found in the authority source, if the provider has a California License.

2. Transposition error: Names are checked for potential transposition with transposed names flagged in the detail result file. Please refer to the User Guide for Provider Data Discrepancy Review for more details on how to locate this discrepancy in the Detail Discrepancy File

3. “Formerly known as” validation: Input names are matched to “Formerly Known As” field in NPPES or DEA database. Formerly known as names are flagged in the detail result file. Please refer to the User Guide for Provider Data Discrepancy Review for more details on how to locate this error.

QHP FAQs Examples

http://www.mbc.ca.gov/http://www.ombc.ca.gov/http://www.dca.ca.gov/

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